Abstract

Traditionally, schools of nursing teach legal and ethical responsibilities at the pre-licensure and advanced practice levels, with emphasis on legal duties and ethical principles. However, involving clinicians in the process of ethical reasoning, a process similar to the scientific method and nursing process, is much less common. The current article describes and demonstrates the steps in ethical reasoning in common situations faced by prescribing advanced practice RNs and psychiatric–mental health nurses. [Journal of Psychosocial Nursing and Mental Health Services, 57(1), 7–10.]

Abstract

Traditionally, schools of nursing teach legal and ethical responsibilities at the pre-licensure and advanced practice levels, with emphasis on legal duties and ethical principles. However, involving clinicians in the process of ethical reasoning, a process similar to the scientific method and nursing process, is much less common. The current article describes and demonstrates the steps in ethical reasoning in common situations faced by prescribing advanced practice RNs and psychiatric–mental health nurses. [Journal of Psychosocial Nursing and Mental Health Services, 57(1), 7–10.]

Every nurse has had some class or course in ethics of nursing and ethics in general (Cooper, 2012). Ethics is often taught in conjunction with legal responsibilities, even though they are different entities. Laws are created to ensure that moral and ethical behaviors essential to a society are required, with clear consequences to lapses in these behaviors. Ethics is a discipline that systemizes, defends, and recommends concepts of right and wrong, good and bad, and moral duty and obligation (Merriam Webster Dictionary, 2018). Ethics is usually taught as a set of principles such as beneficence, non-maleficence, justice, autonomy, and truthfulness. But how do nurses use these principles to reason through a clinical situation or ethical dilemma that lacks a clear-cut answer? Even more troublesome is how clinicians use ethical reasoning in addressing issues around prescribing medications and helping clients take their medications. This column ventures away from the factual process of psychopharmacology and focuses on the ambiguous process of ethical reasoning related to psychopharmacology.

Ethical Reasoning Process

Ethical reasoning is how to think about issues of right and wrong (Sternberg, 2012) following a process similar to the scientific method and nursing process. Ethical reasoning follows systematic steps moving from identifying and clarifying the issue, seeking specifics of the problem or situation, finding evidence in the literature about the problem and solutions, identifying possible solutions, deciding on best options, and enacting a solution. In essence, ethical reasoning is a method of practical ethics that nurses use to make decisions about practice (Spielthenner, 2017). Nursing, like most professions, has a code of ethics, but the code does not always help nurses think through a course of action, especially when there are conflicting demands and particular nuances of a situation. By following a series of steps and completing each thoroughly, it is more likely nurses will act ethically and be able to defend their actions responsibly.

Take personal responsibility for generating an ethical solution to the problem.

Determine what abstract ethical rule(s)/principles might apply to the problem (including any codes of ethics relevant to the situation).

Decide how these abstract ethical rules apply to the problem to suggest a concrete solution.

Prepare to counteract contextual forces that might lead one not to act in an ethical manner.

Act.

Two scenarios are shown below in which these steps are applied. Although ethical behavior is mostly thought of in terms of patient situations, ethical dilemmas also arise in professional acts adjacent to patient care.

Scenario 1: Client not Taking Current Medications

Due to paranoid delusions, a client with severe psychotic disorder decides to stop current medication that is reasonably effective in managing positive symptoms and less effective in managing negative symptoms. The client has been functional with lurasidone for more than 1 year, but has experienced severe metabolic syndrome with quetiapine, olanzapine, and risperidone in the past. Changing to another medication is not warranted, as he has done well with minimal side effects. How does the nurse ethically negotiate with the client and family in deciding to maintain the current medication?

Recognize that there is an event to which to react. There are elements of right and wrong to consider in advocating for the client and family as well as meeting responsibilities within the facility in which the nurse works.

Define the event as having an ethical dimension. The ethical issues involved are preserving the client's autonomy in making decisions for himself versus recognition that his decision-making capacity is impaired by his delusional symptoms. The nurse's dilemma is advocating for him in his right to make the decision and helping him manage disturbing symptoms with medication that has served him in the past.

Decide that the ethical dimension is significant. The principles of beneficence and non-maleficence are in question. The nurse may have knowledge from the client's previous care that suspending this medication has resulted in symptom escalation and hospitalization, yet the client's insistence jeopardizes his continuation of the relationship with the nurse.

Take personal responsibility for generating an ethical solution to the problem. The easy way out is to let the client decide the course of events and passively wait to see what happens. But is this the ethical route? The nurse decides to involve the client in problem solving, and thus in the nurse's ethical dilemma.

The nurse practices with compassion and respect for inherent dignity, worth, and unique attributes of every person.

The nurse's primary commitment is to the patient, whether an individual, family, group, community, or population.

The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.

The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and acts consistent with the obligation to promote health and to provide optimal care.

Decide how these abstract ethical rules apply to the problem to suggest a concrete solution. This is not as clear cut as the previous steps. The nurse needs to consider the quality and strength of the relationship with the client. Does he trust the nurse sufficiently to suspend his delusional thinking? Can the nurse allow flexibility in the treatment plan to have a drug holiday under close monitoring by the family and nurse/treatment team? Review with the client how he responded previously when he stopped his medications and what that felt like for him. Explore the pros and cons of stopping the medication. Are there other issues (e.g., cost, side effects, stigmatization, interactions with other medications or substances) that affect his willingness to take medication?

Prepare to counteract contextual forces that might lead one not to act in an ethical manner. The psychiatric– mental health nurse (PMHN) generalist may need to collaborate with the prescriber, which he/she may find intimidating. It may place the nurse at risk for conflict with other staff members, being perceived as overstepping the boundaries of his/her role. The advanced practice RN (APRN) may fear losing the client and family, having the client drop out of treatment, or being accused of patient abandonment.

Act. Weighing all these factors ultimately requires some action; however, the default mode could be passivity (i.e., waiting for the client to act and risk the consequences), which is not an ethical behavior. Scheduling more frequent appointments or observational episodes with the client and increasing availability to the client and family members within HIPAA boundaries might mitigate potential harm and allow more rapid intervention if necessary.

Scenario 2: Off-Label Prescribing

An APRN has several clients with treatment-resistant depression (TRD). He has tried several lengthy trials of serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, norepinephrine dopamine reuptake inhibitor (bupropion), serotonin modulators (e.g., vortioxetine), and adjunctive lithium and/or serotonin dopamine antagonists (e.g., aripiprazole, brexpiprazole) with minimal response. He applied different psychotherapy approaches, including cognitive-behavioral therapy and psychodynamic therapy. He has read about ketamine infusions at subanesthetic dosages to treat TRD; however, the U.S. Food and Drug Administration (FDA) considers this off-label use. The APRN has skill in venipuncture, has read extensively the research on ketamine for TRD, and recognizes that ketamine infusions may be effective treatment for his clients. He also finds this treatment could be lucrative, as the average cost is $1,000 per treatment, is usually given two times per week for 2 to 3 weeks, and is not reimbursable by third-party payers. What is the ethical action for the APRN?

Recognize that there is an event to which to react. The event to consider is the APRN's desire to offer ketamine infusions for clients with TRD in a safe and effective manner.

Define the event as having an ethical dimension. The ethical issue is that this is an off-label application requiring additional skills of the nurse (i.e., venipuncture, monitoring a 30-minute infusion that may or may not be within his scope of practice as a PMHN practitioner). Does he have sufficient knowledge and skills to provide this treatment safely and within the realm of the state nurse practice act?

Decide that the ethical dimension is significant. The APRN would need to clarify with the state board of nursing (SBN) if offering ketamine infusions is within his scope of practice. Because the treatment is off-label, what are the risks and benefits and what is the evidence to support the effectiveness of the treatment?

Take personal responsibility for generating an ethical solution to the problem. The APRN needs to do a full and complete literature search on ketamine, including mechanism of action, methods and procedures of administration, immediate and long-term side effects, and necessary equipment for the treatment and management of potential side effects. He must also consider potential collaborative professional relationships and policy and procedure documents needed to render treatment.

Determine what abstract ethical rule(s)/principles might apply to the problem (including any codes of ethics relevant to the situation). The salient issue is balancing the benefits of treatment with the risks to a vulnerable population of patients who are desperate for relief. Social justice applies as this treatment would likely require out-of-pocket expense to the patient at a fairly high cost with little experience in how long the treatment benefits would last. Similarly, the APRN needs to consider the extent to which profit motive balances with beneficence and non-maleficence and possible conflict of interest. With minimal published results of the long-term effects of treatment for TRD, the burden is on the APRN to protect the patient.

Decide how these abstract ethical rules apply to the problem to suggest a concrete solution. If the SBN rules that this is within nursing scope of practice, the APRN must demonstrate the knowledge and skill to deliver an off-label treatment. He also needs to reflect on conflict of interest of possible personal profit at the risk of his patients' gain.

Prepare to counteract contextual forces that might lead one not to act in an ethical manner. The APRN creates a portfolio of research articles on ketamine infusion for TRD to support his knowledge. He updates his cardio-pulmonary resuscitation skills at the advance cardiac life support level to prepare for extraordinary cardiorespiratory adverse effects and his assessment skills for psychotic and dissociative adverse effects. He contracts with a certified nurse anesthetist to collaborate on a treatment plan and assist with treatment. He also considers carefully how he will offer such treatment to clients, which clients would best benefit with minimal risk, and alternatives to offer those clients who do not want this treatment or whom the APRN is uncomfortable with offering this treatment option.

Act. The APRN decides to proceed with this treatment option on a limited basis. He consults with his attorney for advice regarding liabilities and review of consent and procedure forms. He creates a policy and procedure document using the research literature and extant best practices. Lastly, he notifies his intentions to the SBN for information only. The more difficult aspect for the APRN, however, is justifying costs of services and potential profit for him considering the vulnerability of his clients.

At the time of this publication, no SBNs have approved ketamine infusions within the APRN scope of practice. Each state regulates APRNs' off-label use of medications. From an ethical perspective, the nurse is responsible for knowledge and skill base to support a decision to prescribe outside the bounds of FDA approval.

Conclusion

Although nurses strive to act ethically, not all have received the necessary preparation. It seems easier to act ethically than otherwise; however, when confronted with clinical situations with multiple conflicts, nurses need some way of reasoning through the issues within ethical principles. Acting ethically comes at some cost and strain. Ultimately, thinking through the ethical dilemma results in acting and evaluating one's behavior. There are no distinct right and wrong answers to ethical dilemmas. Thinking through the options, providing strong arguments for decisions, and taking responsibility for one's actions are difficult yet necessary steps for a successful career.